Complete all of the forms below and return this
packet to your MESA advisor.
Enrollment
Form/
Forma de
Matriculacíon
Please DO NOT leave
any line empty and
complete entire form.
Por favor NO DEJE
ninguna línea vacía y
complete la forma
entera.
Parent
Authorization
Form /
Autorización de
Padres
Parent/Guardian must
complete the entire
form.
El padre o guardián
legal debe llenar ésta
forma.
Student Conduct
Agreement /
Acuerdo de
Conducta
Estudiantil
Student must print
name, sign, and date.
El estudiante debe
incluir su nombre,
@irma, y la fecha.
ion 2009
UC Irvine MESA
Elementary & Middle School
Enrollment Application 2012-2013
APPLICATION/ENROLLMENT FORM (EF) AY 2012-2013
PLEASE COMPLETE ALL ITEMS AND PRINT CLEARLY – Required Fields are in BOLD
School this year: ___________________________________ Are you a returning MESA student? Yes No
Student ID at School District: __________________________________ Social Security Number: _________-________-___________
Last Name: ______________________________ First Name: ______________________________ M.I.: ________
Email Address (required if allowing student login):_____________________________________________________
Permanent Address:______________________________________________________________________________ City: _________________________________________________ State: _________ Zip: __________________
Primary Phone: (_____)______-___________ Secondary Phone: (_____)______-___________ Gender: Male Female Grade Level: ______
Ethnicity (please write the corresponding number(s) into the space provided): _________ 01 African American / Black
03 Chinese/Chinese-American 05 Filipino/Filipino-American 07 Korean/Korean-American
09 Pacific Islander (includes Micronesian,
Polynesian, other Pacific Islanders)
11 White/Caucasian
13 Other Spanish-American/Latino
(includes Cuban, Puerto Rican, Central and South American)
15 Decline to State/Don't Know Birthdate: ____/____/____
Is a language other than English spoken regularly in your home? 1.No 2.Yes, specify ___________________
Summer Programs Participated in Past Summer (please check all that apply): 1. MESA Summer Program
2. Summer Advancement Academy (SAA) 3. Summer Job
4. Other Program, please specify ______________________________ Other Academic Programs Participated (please check all that apply):
1. Puente
2. UC Early Academic Outreach
3. CSU Early Outreach
4. Upward Bound
5. AVID 6. COSMOS
Primary Career Interest (please check one):
1. Engineering 6. Other Math-Based Careers
2. Computer Science 7. Health Profession 3. Physical Science 8. Non-Math Based Career 4. Mathematics 9. Don't Know
5. Business
1. Parent/Guardian Name: __________________________ Phone: (_____)______-___________ 2. Parent/Guardian Name: __________________________ Phone: (_____)______-___________
Highest level of education achieved by each of your parents or guardians? (please write the corresponding number into the boxes):
Parent 1 Parent 2
1. No school/elementary school 6. Community college degree 2. Eighth grade or less 7. 4-year college degree
3. Some high school 8. Beyond 4-year college degree 4. High school graduate 9. M.S./M.A./M.B.A./Ph.D degree
5. Some college or university 10. Don't know
02 American-Indian/Alaskan Native 04 East Indian/Pakistani 06 Japanese/Japanese-American 08 Mexican/Mexican-American/Chicano 10 Vietnamese/Vietnamese-American 12 Other Asian (Not including Middle
Eastern)
What type of work have your parents or guardians typically done over the past years or prior to retiring? (please write the corresponding number into the boxes):
Parent 1 Parent 2
1. Engineer 7. Factory worker
2. Computer Scientist 8. Farm worker
3. Other Professional 9. General worker
4. Manager/Supervisor 10. Never employed
5. Sales/Clerical 11. Don't know 6. Skilled technician, trade
I give my permission for MESA to obtain information about my academic performance from schools, colleges, and testing agencies, to give my name and address to college and employer representatives, and to use my name, photograph and quotes in MESA-related press releases and materials.
Student's Signature: __________________________________________________ Date: ____________________
MSP 12-13
List your Fall courses below:
Student Name _______________________________________ School ______________________________________ Period/Course Title Teacher Room
0._______________________________ _________________________________ _________________________ 1._______________________________ _________________________________ _________________________ 2._______________________________ _________________________________ _________________________ 3._______________________________ _________________________________ _________________________ 4._______________________________ _________________________________ _________________________ 5._______________________________ _________________________________ _________________________ 6._______________________________ _________________________________ _________________________ 7._______________________________ _________________________________ _________________________ 8._______________________________ _________________________________ _________________________ 9._______________________________ _________________________________ _________________________ Home Room______________________ _________________________________ _________________________ For MESA Center use only:
Is the student an ELL student: Yes No
EDI criteria met: EC1[ ] EC2[ ] EC3[ ] Termination reason:
PP1[ ] PP2[ ] PP3[ ] PP4[ ] [ ] graduated or will graduate in Spring ED1[ ] ED2[ ] ED3[ ] ED4[ ] [ ] transferred to a non-MESA school FH1[ ] FH2[ ] FH3[ ] FH4[ ] FH5[ ] FH6[ ] [ ] dropped because of lack of interest PI[ ] [ ] dropped because no college-track math OI1[ ] OI2[ ] OI3[ ] OI4[ ] [ ] dropped for low grades
PARENT AUTHORIZATION ACADEMIC YEAR 2012-2013
Student Name School
I, , parent or legal guardian of the above-mentioned student, hereby give permission for my child to participate in MESA activities conducted by the University of California. I understand that the primary objective of the program is to encourage students to enroll in college preparatory courses and participate in MESA academic support services. I also understand that such activities may be available until he/she enrolls at a college or university.
I hereby authorize MESA Program directors, staff and their assistants to engage in the following:
1. To have access to, and to make and receive copies of, my child’s academic school records through the completion of the 12th grade. I understand that these records will be kept in strict confidence and will be used to: a) monitor my child’s academic progress; and b) determine when additional academic support services are needed.
2. To disclose information from my child’s academic records to designated representatives of colleges and universities so they may determine my child’s eligibility for admission at their institutions, his/her need for special services, and for general use in planning outreach and recruitment activities. These records will be maintained by the University of California consistent with the Federal Family Education Rights and Privacy Act of 1974, applicable state laws and University policies.
3. To allow my child to attend field trips and events sponsored and coordinated by the MESA Program. I understand that my child will have adult supervision while on these field trips.
4. To use my child’s name, photograph, digital image, and quotes in MESA-related press releases and materials. I certify that I have read and understand any rules and safety provisions established for this program.
In addition, I agree to assume full responsibility for any risk of injury, death, or property damage arising out of my child’s participation in the program and I give permission for my child to receive, if necessary, emergency medical services by authorized personnel, and that any cost incurred as a result of such medical emergency will be solely my responsibility. I further release the University from any liability on account of injury to or death of my child arising out of my child’s participation in MESA activities and hold the University harmless for any damage or costs that may be incurred due to the acts of my child during participation in this program.
I understand that this consent may be withdrawn at any time by my written directions to the MESA Program Director.
Parent or Legal Guardian’s Signature Date Parent or Legal Guardian (Please print)
Address City Zip
Home Phone Number Emergency Phone Number Special Instructions:
AUTORIZACION DE PADRES ANO ACADEMICO 2012-2013
Nombre del Estudiante Escuela
Yo, , padre o tutor del estudiante previamente mencionado(a), por la presente doy permiso para que mi hijo(a) participe en actividades del programa MESA dirigidas por la Universidad de California. Entiendo que el propósito principal del programa es animar a los estudiantes para que se inscriban en cursos preparatorios para estudios universitarios y participen en los servicios de apoyo académico ofrecidos por el programa MESA. También entiendo que tal actividades pueden ser disponibles hasta que el(ella) se inscriba en un colegio o universidad.
Por consiguiente, autorizo a los directores, personal y asistentes del programa MESA en lo siguiente:
1. Tener acceso a, y hacer y recibir copias, del expediente académico de mi hijo(a) hasta que complete la escuela secundaria. Entiendo que éste expediente será guardado en confidencia estricta y será usado para supervisar el progreso académico de mi hijo(a) y determinar si son necesarios servicios adicionales de apoyo académico. 2. Proporcionar información del expediente académico de mi hijo(a) a representantes designados de colegios o
universidades para que puedan determinar la elegibilidad de mi hijo(a) para su ingreso a sus instituciones, su
necesidad para servicios especiales, y para uso general en la planificación de actividades de reclutamiento y alcance comunitario. Esta información se mantendrá por la Universidad de California en acuerdo con la ley: Federal Family
Education Rights and Privacy Act of 1974, las leyes estatales aplicables, y pólizas de la Universidad.
3. Permitir que mi hijo(a) asista a excursiones y eventos patrocinados y coordinados por el programa MESA. Entiendo que mi hijo(a) tendrá supervisión adulta en estas excursiones.
4. Usar el nombre, imagen y citas de mi hijo(a) en comunicados de prensa y materiales relacionados con el programa MESA.
Certifico que he leído y entiendo las reglas y provisiones de seguridad establecidas por el programa.
Además, estoy de acuerdo en asumir la responsabilidad total de cualquier riesgo de herida, muerte o daño a propiedad que resulte de la participación de mi hijo(a) en el programa y doy permiso para que mi hijo(a) reciba, si es necesario, servicios médicos de emergencia de parte de personal autorizado, y que cualquier costo que resulte de tal emergencia médica será solamente mi responsabilidad.
Por lo tanto, libero a la Universidad de California de cualquier obligación por causa de herida o muerte de mi hijo(a) que resulte de su participación en actividades del programa MESA y mantengo sin perjuicio a la Universidad de cualquier daño o costo que pueda resultar debido a las acciones de mi hijo(a) durante su participación en el programa.
Entiendo que este consentimiento puede ser retirado en cualquier momento por medio de mis instrucciones escritas al Director del Programa MESA.
Firma del Padre o Tutor Fecha Nombre del Padre o Tutor (Favor de escribir en letra de molde)
Domicilio Ciudad Código Postal Teléfono de Casa Teléfono de Emergencia
University Of California, Irvine
Mathematics, Engineering, Science Achievement Program
Student Conduct Agreement
2012-2013
__________________________ ________________________ ____________
Student Name School Grade
************************************************************************************************* 1. Participants may not leave the school campus during Program sessions.
2. Participants may at no time leave the University campus and must stay within designated areas at all field trip sites. 3. Participants agree to have no outside visitors during the Program sessions except parents/guardians.
4. Tampering with any fire equipment is a misdemeanor subject to a $1,000.00 fine or one year in prison at participant’s expense.
5. Participants who abuse or damage University or school property will be billed for the cost of the damage.
6. Participants are expected to attend all sessions. Special circumstances such as illness will be considered on an individual basis and will require the participant to notify the MESA program and/or MESA advisor.
7. Participants must be in their assigned rooms by the designated time. Participants must be considerate of other class sessions and control noise level at all times.
8. Cellular phones and other electronic devices must remain off and will not be allowed during Program sessions. 9. Participants must not dress inappropriately (i.e. cut-off or short shorts, mid-drift or low-cut tops, clothing
w/inappropriate language or artwork).
10. Participants will be expected to show proper respect to all advisors, program staff and student participants in the program.
11. Participants must not make inappropriate comments, phone calls, and/or correspondences (this includes hard copy or electronic messages) to advisors, program staff and student participants.
12. No inappropriate physical conduct is permitted (i.e. shaking, pushing, kicking, inappropriate touching).
13. Violence and abuse of any type will not be permitted. Violence and abuse could mean fist fights, water fights, verbal abuse of others, and any form of conduct which may cause another individual harm (or potential harm),
or unnecessary feelings of discomfort.
14. Consumption or possession of alcoholic beverages or illegal drugs of any kind will not be permitted. 15. Smoking is not permitted.
16. Program staff must be notified of any prescription drugs.
17. Possession of any type of weapon will not be permitted. Weapons include knives, guns, pellet guns,
B-B guns, sling shots, water pistols, or any other kind of device that could inflict injuries to yourself or others.
I, , understand that my participation in the MESA
(please print name)
program will be in jeopardy of being terminated for failure to abide by the rules of conduct stated above. Student's signature Date
